Provider Demographics
NPI:1619338902
Name:BURTON, SAMANTHA MICHELLE (R1233810716)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MICHELLE
Last Name:BURTON
Suffix:
Gender:F
Credentials:R1233810716
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 ESTHER DR APT D
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93308-2397
Mailing Address - Country:US
Mailing Address - Phone:661-410-9506
Mailing Address - Fax:
Practice Address - Street 1:1124 BAKER ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93305-4322
Practice Address - Country:US
Practice Address - Phone:661-327-9376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAR1233810716101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program